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Epidemiology

Simple supracondylar fractures are typically seen in younger children, and are uncommon in adults; 90% are seen in children younger than 10 years of age, with a peak age of 5-7 years 4,6. These fractures are more commonly seen in boys 4.

These injuries are almost always due to accidental trauma, such as falling from a moderate height (bed/monkey-bars) 4.

Rarely (<5%) supracondylar fractures are seen due to a fall onto the flexed elbow. They occur in older individuals and require different management and are discussed separately: see flexion supracondylar fracture5.

Mechanism

Typically supracondylar fractures occur as a result of a fall on a hyper-extended elbow. They result in an extra-articular fracture line, and (when displaced) posterior displacement of the distal component.

Plain radiograph

Lateral and AP radiographs are usually sufficient, and in many instances demonstrate an obvious fracture. Often, however, no fracture line can be identified. In such cases assessing for indirect signs is essential:

anterior fat pad sign (sail sign): the anterior fat pad is elevated by a joint effusion and appears as a lucent triangle on the lateral projection

Treatment and prognosis

Although in many cases the fracture is easily seen, in some instances all that may be seen is soft tissue swelling or an anterior fat pad sign. Even in the absence of an obvious fracture, the patient needs to be treated with a cast. Repeating radiographs after inflammation has subsided may be helpful in demonstrating the fracture; this is typically done 7-10 days later.

Management depends on the type and degree of angulation 5,7.

Type I

Type I (undisplaced) fractures are stable and can be treated with cast immobilization for approximately 3 weeks.

Type II

Type IIa usually require reduction (especially when angulation is more than 20 degrees). Although traditionally these fractures were treated non-operatively with cast immobilization of the flexed arm to 120 degrees, this however dramatically increases the risk of ischemic contracture (Volkmann contracture), as such most authors recommend percutaneous pinning (CRIF) and cast immobilization with less than 90 degrees flexion 5,7. Type IIb always required reduction +/- fixation.

Type III

Type III fractures can sometimes be treated similarly to type II (closed reduction and percutaneous pinning, CRIF) although frequently the fracture is held open by interposed soft tissues requiring open reduction 7.